Good Faith Estimate
Effective January 1, 2022, a ruling went into effect called the “No Surprises Act,” which requires mental
health practitioners to provide a “Good Faith Estimate” (GFE) about out-of-network care to any patient who is uninsured or who is insured but does not plan to use their insurance benefits to pay for health care items and/ or services.
The Good Faith Estimate works to show the cost of items and services that are reasonably expected for
your mental health care needs for an item or service. The estimate is based on information known at the
time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected
costs that may arise during treatment.
You are entitled to receive this “Good Faith Estimate” of what the charges could be for counseling
services provided to you. While it is not possible for a counselor to know how many sessions may be
necessary or appropriate for a given person upon the initiation of services, this form provides an estimate
based on certain circumstances.
Your total cost of services will depend upon the number of sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.
This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor
does it include any services rendered to you that are not identified here.
The fee for a traditional 50-minute counseling session (in-person or tele-health) is $235.00. Most clients
will attend one counseling visit per week, but the frequency of visits that are appropriate in your case may be more or less than once per week, depending upon your individual needs and preference. You may
project any potential future cost(s) by multiplying the session fee of $235.00 by the total number of
sessions. This will result in your total estimated cost for mental health service(s).
For example, $235 session fee x 8 sessions = $1,880.00.
If you engage in counseling services for a longer period, your total estimated charges will increase
according to the number of visits and length of treatment.
This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of visits. The number of visits that are appropriate in your
case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your counselor.
You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
We are providing you with this Good Faith Estimate based on the information the clinician has available
at this time and actual items, services, or charges may differ from this good faith estimate as treatment
progresses. Here is a chart of typical fees for services the practice provides that will be in effect for June
1, 2025 through December 31, 2025. Please note that these fees are the same for both in-office and telehealth services.
During the course of treatment, you may be subject to additional costs based on time, frequency, and
services rendered. See below for a list of possible additional services:
Additional Costs Include
Late Cancellation Fee: $235 (full session rate)
Extended 80 minute session: $352.50 (1.5x session rate)
Record Request Fee: $40-$100 depending on page count
Consultation With Other Providers: No charge
Letter or Report Writing: $117.50 per hour (pro-rated)
Crisis Communication (between sessions): No charge unless discussed
Travel Time for Out of Office Sessions or Court Appearances: N/A – not provided
Forensic and/or Legal Fees: N/A – not provided
KK Therapy Group, PLLC recognizes every client’s mental health journey is unique. How long you
need to engage in counseling and how often you attend sessions will be influenced by many factors
including:
● Your schedule and life circumstances
● Counselor availability
● Ongoing life challenges
● The nature of your specific challenges and how you address them
● Personal finances and resources
You and your counselor will continually assess the appropriate frequency of sessions and will work
together to determine when you have met your goals and are ready for discharge. You may request a new
Good Faith Estimate at any time in writing during your treatment.
Good Faith Estimate Disclaimer:
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your
health care needs for an item or service. The estimate is based on information known at the time the
estimate was created. Your provider may recommend additional services that are not reflected in this
Good Faith Estimate.
The Good Faith Estimate is only an estimate—actual items/ service charges may differ. The Good Faith
Estimate does not include any unknown or unanticipated costs that may arise and are not reasonably
expected during treatment due to unforeseen events. You could be charged more if complications or
special circumstances occur. Other potential items and/ or services associated with counseling charges
may include but is not limited to no show/ late cancellation fee(s), record request(s), letter writing(s),
legal fee(s)/ court attendance(s), professional collaboration(s), and in-between session supports).
These potential items / services and associated fee(s) are discussed further within the “Therapy Consent,
Policies, and Agreements” documentation and should these items / services be initiated a new Good Faith
Estimate will be provided. The Good Faith Estimate does not obligate the client to obtain listed items or
services.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during
treatment. You could be charged more if complications or special circumstances occur. If this happens,
and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that
provider or facility, federal law allows you to dispute the bill.
You are encouraged to speak with your provider at any time about any questions you may have regarding
your treatment plan, or the information provided to you in this Good Faith Estimate. You may contact the
health care provider or facility listed to let them know the billed charges are higher than the Good Faith
Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill,
or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services
(HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120
calendar days (about 4 months) of the date on the original bill.
If you dispute your bill, the provider or facility cannot move the bill for the disputed item or service into
collection or threaten to do so, or if the bill has already moved into collection, the provider or facility has
to cease collection efforts. The provider or facility must also suspend the accrual of any late fees on
unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility
cannot take or threaten to take any retributive action against you for disputing your bill.
There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing
your dispute agrees with you, you will have to pay the price on this Good Faith Estimate, reduced by the
$25 fee. If the SDR entity disagrees with you and agrees with the health care provider or facility, you will
have to pay the higher amount. To learn more and get a form to start the process, go to http://www.cms.gov/
nosurprises/consumers or call 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit
http://www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call
1-800-985-3059.
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